Evidence Based Information - why didn't it work in practice?

Helen Stapleton, Department of Midwifery, Sheffield University.

This presentation reports on research findings from a recent evaluation of the MIDIRS Informed Choice leaflets1.

Background
The move towards evidence based care was an important factor in the production of the MIDIRS informed choice leaflets2. A combination of qualitative and quantitative methods were used to examine issues underpinning the transfer and utilisation of pregnancy related information, with particular emphasis on evaluating these same leaflets. The research project was a collaborative, multidisciplinary venture involving a number of different departments within the Universities of Sheffield and Glamorgan.

Design
The research was undertaken in two phases. Phase one consisted of an ethnographic study of three maternity units in the UK where the leaflets were already in use. Two of these units were in England and one was in Wales. This phase informed the development of the (postal) questionnaire for the cluster randomised controlled trial (CRCT). Phase two consisted of a CRCT in thirteen maternity units in Wales. The thirteen units were reduced to ten for the purpose of randomisation. Five units were randomly allocated to the control arm and five to the intervention arm, where the full set of the MIDIRS informed choice leaflets were used for a period of eight months.

Methodology
Quantitative: Postal questionnaires were sent to two unrelated cohorts of ante-natal and post-natal maternity service users on all sites before and after the introduction of the leaflets. The questionnaires examined a range of outcomes, including perceptions of informed choice, decision making, knowledge, satisfaction and anxiety.
Qualitative: Included observation work, field notes, in-depth interviews and focus groups with service users and a range of health professionals. The qualitative fieldwork was undertaken on all sites between the two questionnaire mailings. A Grounded Theory3 approach informed the qualitative data collection.

Data analysis
The questionnaire data was analysed using SPSS and MLWin. A Grounded Theory approach informed the analysis of the qualitative data. This was assisted by the software package NUD*IST (Non-numerical Data Information Systems and Technology)..

Results
The primary outcome was the change in the proportion of women agreeing with the statement that they had had 'enough information and discussion with midwives or doctors to make a choice together about all the things that happened during maternity care'. Between 92% and 99% of women who received each leaflet reported that it was helpful or very helpful. However, there was no evidence that the leaflets were effective in increasing the proportion of women who reported having exercised informed choice.

This presentation describes some of the dilemmas surrounding the use of the Informed Choice leaflets in clinical practice and proposes explanations for the failure of the leaflets to achieve change.

Funding Department of Health through The York Centre for Dissemination and Reviews


References

1Kirkham M and Stapleton H (eds) Informed choice in maternity care: an evaluation of evidence based leaflets. University of York: NHS Centre for Reviews and Dissemination, 2000 (in press).
2MIDIRS informed choice leaflets (1995/6) MIDIRS (Midwives Information and Resource Service) and The NHS Centre for Reviews and Dissemination. Bristol
3Strauss A & Corbin J (1990) Basics of Qualitative Research: Grounded Theory Procedures and Techniques. London: Sage.


correspondence to:
Helen Stapleton RN, SCM, MNIMH, MSc research midwife
University of Sheffield, Winter St, Sheffield S3 7ND 0114 222 9872 h.stapleton@sheffield.ac.uk